Individual & Family Plans

Complete Care

Highlights: TRH Health Plans uses Blue Network P. Please keep in mind that in-network payments are based on negotiated fees. If an out-of-network provider is used, the member’s liability will increase significantly.

About the Plan

Looking for a simple approach to complete health care coverage? Check into TRH Complete Care, which offers health, dental and vision coverage all under one plan. Prescription drug coverage is also included.  Available for individuals or families. 



Download Schedule of Benefits

Overview

  In Network Out of Network
Calendar Year Deductible1
(Unless otherwise indicated, all benefits are subject to the deductible)
$1,500 per member $1,500 per member
Out of Pocket Maximum(OOP)2 $7,500 for individual coverage
$15,000 for family coverage
Unlimited
Lifetime Benefit Maximum Unlimited Unlimited
Footnotes
  1. Deductible per member per calendar year.
  2. Once the OOP maximum is met, benefits are provided at 100% for a member for the remainder of the calendar year. This applies to in-network provider services only. Copayments do not apply to OOP and must still be paid after OOP is met.

Services

  In Network Out of Network
Office Visit $25 copayment* per visit
(Not subject to the calendar year deductible)
Deductible/Coinsurance
Coinsurance 20% of eligible charges
(plan pays 80% of eligible charges)
40% of eligible charges
(plan pays 60% of eligible charges)
Preventive Care Benefits
Routine Physical Exam3 All charges over $150 Not Covered
Well Child Services4 $25 Not Covered
Annual OB/GYN Exam5 $25 Not Covered
Routine Colonoscopy6 20% 40%
Annual Routine PSA7 20% 40%
Annual Routine Pap Smear8 20% 40%
Mammogram9 20% 40%
Emergency Services
Emergency Room (not resulting in admission )
$75 Deductible per visit
(in addition to calendar year deductible)
$75 Deductible per visit
(in addition to calendar year deductible)
Prescription Drug Coverage
($7,500 calendar year maximum per member)
  • Generic | TRH Health Plans will reimburse 100% of the maximum allowable charge, after deductible, when purchased at an in-network pharmacy
  • Brand Name| TRH Health Plans will reimburse 75% of the maximum allowable charge, after deductible, when purchased at an in-network pharmacy
Home Delivery service is also available
Dental
  • Routine dental services, including two exams, cleanings, x-rays and fillings10
    • There is a $25 copay for preventive and restorative services
    • Maximum benefit per member, per calendar year is $500
Vision
  • Routine vision benefits including eye exams, eyeglasses and contact lenses10
    • Maximum benefit per member, per calendar year for eyeglasses or contacts is $100
    • Maximum benefit per member, per calendar year for eye exam is $40
Footnotes
  1. After a 6 month waiting period from the member’s effective date, benefits will be available for members 7 years of age and above for a routine physical examination and related services up to $150 annually when provided and billed by an in-network provider. Deductible, copayment and OOP maximums do not apply. All charges over the $150 limit are the member’s responsibility.
  2. Benefits are available, subject to the copayment, for a member under the age of 7 for physical examinations and appropriate immunizations/vaccinations when services are rendered by an in-network provider. Exams not used during the time periods below do not carry over to the next time period.
    Physical Examination Guidelines:
    Age Number of exams
    Under age 1 4 exams from birth to the child’s first birthday
    Age 1 2 exams from the child’s first birthday to the child’s second birthday
    Age 2 through 6 1 exam per year (determined by the child’s birthday)
  3. Benefits will be available, subject to the copayment, for 1 routine OB/GYN exam per calendar year. Lab services, such as the reading of a pap smear, associated with this visit are subject to deductible and coinsurance.
  4. Benefits will be provided for 1 routine colonoscopy every 4 years for members age 50 and over when provided by an in-network or out-of-network provider, subject to the deductible and coinsurance.
  5. Benefits will be provided, subject to deductible and coinsurance, for 1 routine PSA per calendar year when services are rendered by an independent laboratory or other outpatient setting.
  6. Benefits will be provided, subject to deductible and coinsurance, for the interpretation of one routine pap smear per calendar year when services are rendered by an independent laboratory or other outpatient setting. Services rendered in an in-network physician’s office will be subject to the copayment. Services rendered in an out-of-network physician’s office will be subject to the deductible and out-of-network coinsurance.
  7. Benefits will be provided, subject to deductible and coinsurance, for routine mammography screening provided such examinations are conducted upon the recommendation of the member’s physician. One baseline routine mammogram will be allowed for members between the ages of 35-39. One routine mammogram will be allowed annually for members age 40 and above.
  8. Subject to a six month waiting period.

Maternity Benefits

Maternity Benefits will be provided after a member’s coverage on a family contract has been in effect for nine consecutive months. Individual coverage has NO maternity benefits.

Pre-Existing Condition Waiting Period

Benefits will not be provided for any pre-existing condition until a member has completed a waiting period of at least 12 months. A pre-existing condition is defined in the contract as “An illness, injury, pregnancy or any other medical condition which existed at any time preceding the effective date of coverage under this contract for which: Medical advice or treatment was recommended by, or received from, a provider of health care services; or symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment.” The pre-existing condition waiting period does not apply to members under the age of 19.

Copayment Guidelines

*Copayments do not apply to the following services: all maternity services, all therapeutic services, allergy testing and injections, behavioral health care, biopsy interpretation, bone density testing, cardiac diagnostic testing, chemotherapy services, chiropractic services, CT scans, CTA scans, dental services, diagnostic services sent out, DME and DME supplies, growth hormone injections, IV therapy, Lupron injections, mammography, MRI, MRA, MRS, nerve conduction tests, neuropsychological or neurological tests, nuclear cardiology, nuclear medicine, orthotics, PET scans, prosthetics, provider administered specialty pharmacy products, sleep studies, surgery performed in a physician’s office and related surgical supplies, Synagis injections, ultrasounds. These services will be covered under normal contract benefits, subject to the terms and conditions of the contract, and deductibles and coinsurance percentages will apply. Copayments do not apply toward satisfying deductibles or out of pocket maximum. Once the deductible and out of pocket maximums are met, copayments still apply.